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Wednesday, March 13, 2019

Retrospective #25: Understanding Your Lipid (Cholesterol) Panel

I am not a doctor or other health
care professional, but I can read a lab test report, especially one that provides
a “Reference Range” and declares a result “IN range” or “OUT OF range,” plus
other guidance, for each test ordered.

At each office visit, my doctor always
orders a complete blood count (CBC) and a metabolic series, including a lipid
panel, plus an A1c. And from time to time, he orders other specialty tests
(High Sensitivity CRP, liver, thyroid, kidney, etc.). This column is going to
be about understanding the lipid panel. That includes Total Cholesterol, HDL-C,
LDL-C (calculated), Triglycerides, and the Total Cholesterol/HDL Ratio. Some
panels now also include non-HDL-C.

Most people know the drill: “high” Total
Cholesterol is not a good thing, and that there is “good” cholesterol (HDL-C)
and a “bad” cholesterol (LDL-C), and that we should try to get our circulating
triglyceride levels down. If we aren’t successful at doing this, by following the doctor’s advice to limit
saturated fat and cholesterol containing foods, he (ort she) is going
to prescribe a statin drug, which will
lower LDL-C and, thereby, Total Cholesterol as well. We are going to be asked
to support this gazillion dollar annual statin industry by taking Crestor,
Lipitor, Zocor, or Simvastatin, the Zocor generic equivalent. (Remember, the
original of this Retrospective was written in 2011.)

This column is not about the efficacy
or safety of prescribing a statin. Personally, I disagree with the current practice.
I do not think statins should be prescribed to anyone without diagnosed heart disease, or anyone over 75 or any
woman whatsoever. There is no proven
benefit. But this column is about “understanding your lipid panel.”

So, let us suppose that two people (or the
same person, in two “snapshots” of lipid panels taken at different times) have
identical Total Cholesterol, i.e.: 200mg/dl (milligrams per deciliter).
One has an HDL-C = 40mg/dl, an LDL-C = 130mg/dl (calculated), a Triglyceride count of 150mg/dl, and a Total Cholesterol/HDL ratio of 5.0. ALL FIVE OF THESE VALUES ARE
BORDERLINE OUT-OF-RANGE. They would appear in BOLD in the “OUT-OF-RANGE”
column on your lab report. Your doctor would tell you, according to my
understanding of the “Standards of Medical Practice,” to cut down on all those
saturated fat and cholesterol containing foods, and immediately start taking a
statin.

Now let’s look at another lipid
panel: Total Cholesterol also200mg/dl, HDL-C = 80mg/dl,
LDL-C = 110mg/dl (calculated),
Triglycerides = 50mg/dl, and a Total
Cholesterol/HDL ratio of 2.5. The
only value that is borderline high in this panel is Total Cholesterol at 200mg/dl. Everything else is textbook WUNDERBAR! The LDL-C is above
optimal (<100mg/dl), but it is a derived
(calculated) value, not a DIRECT value (and in 2018the formula changed).

The formula for LDL-C in the lipid
panel, until 2018, was the Friedewald formula: LDL-C = Total Cholesterol – HDL-C
– Triglycerides/5. And, if your doctor was worried about your less than optimal
LDL’s (because of existing heart disease,
other cardiac risk factors such as
hypertension, obesity, metabolic syndrome or higher than “normal” fasting
plasma glucose or A1c) he could order an LDL direct measurement or an even
more sophisticated VAP test of LDL-C particle size (“A”= “large and buoyant” or
“B” =“small and dense.”) Regardless, this lipid panel would NOT lead your
doctor to prescribe a statinor
suggest a dietary change. He would tell you, “Everything looks great!” and “Continue
with whatever you are doing.” Think about that. Both TC’s (Total Cholesterols)
arethe same: 200mg/dl.

To recap: A Total Cholesterol test
score of 200mg/dl on your lipid panel, with the first set of values above, will put you on dietary
restrictions, and when that “prescription”
doesn’t work, ona statin.
That’s what happened to me. I followed my doctor’s dietary advice, it failed,
and I was on a statin for 5 years,
until I changed my diet…

But if you have a lipid panel like the second
example, you’ll be your doctor’s “poster boy,” as I was after I’d been on a Very
Low-Carb, High-Fat Way of Eating for a year, again on my doctor’s advice. Even
though he started me on LOW-CARB, HIGH-FAT to lose weight, he
doesn’t want to know what I eat. My doctor (a cardiologist) now just tells me
to keep on doing what I’m doing. For him, it’s no more lectures – just smiles,
and when the test results come back, a congratulatory phone call. For my
doctor, my office visit is one of the “high points” of his day, he’s told me.

About Me

I was diagnosed a Type 2 diabetic in 1986. I started a Very Low Carb diet (Atkins Induction) in 2002 to lose weight. I didn’t realize at the time that it would put my diabetes in clinical remission, or that I would be able to give up almost all of my oral diabetes meds. I also didn’t understand that, as I lost weight and continued to eat Very Low Carb, my blood lipids would dramatically improve (doubling my HDL and cutting my triglycerides by 2/3rds) and that my blood pressure would drop from 130/90 to 110/70 on the same meds.
Over the years I changed from Atkins to the Bernstein Diet (designed for diabetics) and, altogether lost 170 pounds. I later regained some and then lost some. As long as I eat Very Low Carb, I am not hungry and I have lots of energy. And I no longer have any of the indications of Metabolic Syndrome.
My goal, as long as I have excess body fat, is to remain continuously in a ketogenic state, both for blood glucose regulation and continued weight loss. I expect that this regimen will continue to provide the benefits of reduced systemic inflammation, improved blood lipids and lower blood pressure as well.